AAPC-CRC Certified Risk Adjustment Coder - Set 3 - Part 1

Correct Answer: Instructions and conventions of the classification

The guidelines state that the instructions and conventions of the classification take precedence over guidelines. The guidelines are a companion that complements and adds to the conventions and instructions within the ICD-10-CM itself. Option a is incorrect because Section IV is simply the part of the guidelines for outpatient coding and reporting, and it ranks below the classification's own instructions. Option b is incorrect because coders apply the guidelines and classification to documentation; nothing gives personal interpretation authority above the instructions and conventions built into the classification. Option d is incorrect because chapter-specific guidelines are part of the guidelines, which are described as accompanying the classification, so they do not override its own instructions.

Correct Answer: Placeholder X

When a code requiring a 7th character has fewer than 6 characters, the placeholder X fills the empty characters. This keeps the 7th character in the 7th position of the data field, as the guidelines require. Option b is incorrect because a default code is the entry listed beside a main term in the Alphabetic Index, representing the most common or unspecified condition, not a character filler. Option c is incorrect because a dash at the end of an Alphabetic Index entry signals that additional characters are needed; it is not entered into a code as filler. Option d is incorrect because NEC means "not elsewhere classifiable" and stands for "other specified" codes; it describes a code's meaning rather than occupying empty positions.

Correct Answer: Immediately following the main term or subterm

The guidelines state that the word "with" in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order. A coder therefore looks for "with" at the start of the subterm list. Option a is incorrect because the guidelines place "with" directly after the main term or subterm it modifies, which is a different position from the end of the entry. Option b is incorrect because the guidelines state that "with" is not placed in alphabetical order, so it does not fall among the subterms by its letters. Option d is incorrect because a default code is the code listed next to a main term, and the guidelines give no sequencing role to "with" relative to it.

Correct Answer: "Other specified" code

In the Alphabetic Index, NEC (not elsewhere classifiable) represents "other specified." When no specific code exists for a condition, the Index directs the coder to the "other specified" code in the Tabular List. Option a is incorrect because unspecified codes are tied to the abbreviation NOS, which is the equivalent of unspecified, and are used when record information is insufficient. Option b is incorrect because an Excludes1 note means "NOT CODED HERE!" and marks conditions that cannot occur together; it has no link to the NEC abbreviation. Option c is incorrect because 7th characters apply only to certain categories and are a separate convention, with a placeholder X filling empty characters, not a meaning of NEC.

Correct Answer: I and II

An Includes note appears immediately under a three-character code title to further define, or give examples of, the content of the category. Inclusion terms are not necessarily exhaustive, and excluded codes are independent of each other. Option b is incorrect because statement III is wrong, since the guidelines say inclusion terms are not necessarily exhaustive and additional terms found only in the Alphabetic Index may also be assigned. Option c is incorrect because statement IV reverses the rule; excluded codes are described as independent of each other, not dependent on one another. Option d is incorrect because both statements fail: inclusion terms may be supplemented by Alphabetic Index terms, and excluded codes are independent of each other rather than dependent.

Correct Answer: Sequencing rules

The Official Guidelines state that "code first" and "use additional code" notes are also used as sequencing rules for certain codes that are not part of an etiology/manifestation combination, such as secondary codes added to fully describe a condition. Option a is incorrect because "see" and "see also" instructions send the coder to other main terms in the Alphabetic Index, not to a sequence for codes. Option b is incorrect because a query is advised when it is unclear whether two conditions under an Excludes1 note are related, not by these notes. Option d is incorrect because an exception to the Excludes1 definition applies when two conditions are unrelated, which is a separate convention from instructional notes that direct code order.

Correct Answer: A sequela with its acute phase

A combination code classifies two diagnoses, a diagnosis with a manifestation, or a diagnosis with a complication. A sequela is a separate concept, and the acute phase code is never used with a late effect code. Option b is incorrect because the guideline lists two diagnoses as the first thing a single combination code is used to classify. Option c is incorrect because a diagnosis together with an associated secondary process, called a manifestation, is named in the guideline as a combination code function. Option d is incorrect because the guideline names a diagnosis paired with its complication as a third situation in which one combination code is used.

Correct Answer: Code it as an additional diagnosis

Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. Only symptoms integral to the disease process are left out as additional codes, so this symptom is reported. Option a is incorrect because a query for clarification applies when documentation of a borderline condition is unclear, and nothing here suggests a borderline diagnosis. Option c is incorrect because that instruction-based exception governs symptoms integral to the disease process, which are not assigned as additional codes unless the classification says otherwise. Option d is incorrect because a confirmed diagnosis only removes symptoms routinely associated with that disease process; additional symptoms not routinely associated should be coded when present.

Correct Answer: The sequela code

Coding of sequela generally requires two codes: the condition or nature of the sequela is sequenced first, and the sequela code is sequenced second. Exceptions apply when the sequela code is followed by a manifestation code or already includes the manifestation. Option a is incorrect because this code is sequenced first, so it holds the opposite position from the one the stem asks about. Option b is incorrect because the guidelines say the acute-phase code for the original illness or injury is not used with a late effect code at all. Option d is incorrect because a combination code classifies two diagnoses or a diagnosis with a manifestation or complication, and it is not the sequela sequencing rule.

Correct Answer: Clinical significance of the condition

Guideline I.B.16 says a condition after care is classified as a complication only when a cause-and-effect relationship exists and the documentation supports that the condition is clinically significant. The word "complication" itself is not required. Option b is incorrect because ICD-10-CM guidance states the provider need not write that word; for example, a condition that alters the course of surgery in the operative report can qualify. Option c is incorrect because querying is directed only when the documentation is unclear about the relationship between the condition and the care, and here the provider has already stated that relationship. Option d is incorrect because observation status already applies in this scenario, and the guideline directs that the complication be reported as a secondary diagnosis there, so no change of status is required.

Correct Answer: The complication

For an admission from outpatient surgery, when the reason for the inpatient admission is a complication, the complication is assigned as the principal diagnosis. The circumstances of the inpatient admission govern the selection. Option a is incorrect because aftercare codes belong to rehabilitation admissions where the treated condition is no longer present, not to an admission from outpatient surgery for a complication. Option b is incorrect because symptom, sign and ill-defined condition codes are not used as principal diagnosis when a related definitive diagnosis has been established, as the complication has. Option d is incorrect because this is assigned only when no complication or other condition is documented as the reason for the inpatient admission, which is not the case here.

Correct Answer: Code both as if confirmed; either may be sequenced first

When two or more contrasting or comparative diagnoses are documented as "either/or," they are coded as if confirmed and sequenced by the circumstances of the admission. If no further determination is possible, either diagnosis may be sequenced first. Option a is incorrect because symptom codes are not used as principal diagnosis when a related definitive diagnosis exists, and the guideline for symptoms followed by contrasting diagnoses was deleted. Option b is incorrect because the guideline directs that all contrasting diagnoses be coded, so leaving one out has no support in the principal diagnosis rules for either/or documentation. Option c is incorrect because the guideline already covers this situation, treating the either/or conditions as confirmed rather than requiring a single diagnosis before coding can proceed.

Correct Answer: II, III, and IV

Outpatient guidelines bar coding uncertain diagnoses and call for symptoms, signs, or abnormal results. The inpatient rule applies to specified hospital admissions, and its basis is that workup, further evaluation, and initial therapy match the established diagnosis. Option a is incorrect because statement I reverses outpatient guidance, which prohibits coding "suspected" conditions; coding them as if established is the inpatient approach, so this pairing includes a false statement. Option c is incorrect because it includes statement I, which misstates outpatient practice, since outpatient coders do not report suspected conditions and instead code to the highest degree of certainty. Option d is incorrect because both statements are true, but the set is incomplete because statement IV, the stated basis for the inpatient rule, is also accurate and is omitted.

Correct Answer: As a history code in a secondary position

The guidelines state that history codes may be used as secondary codes when the historical condition or family history has an impact on current care or influences treatment, which applies in non-outpatient settings such as nursing homes. Option a is incorrect because exclusion applies to earlier-episode conditions with no bearing on the current stay, and this condition influences treatment, so exclusion does not fit. Option b is incorrect because the condition has resolved, and the guidelines provide history codes for such conditions rather than coding them as if they still existed. Option c is incorrect because the guidelines let a history code serve only as a secondary code, so a resolved condition is not elevated to principal diagnosis.

Correct Answer: Report it at each encounter where treatment is received

The outpatient guidelines on chronic diseases state that a chronic disease treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition. Option a is incorrect because the guidelines place no such limit; a chronic disease treated on an ongoing basis may be reported repeatedly, not just at the visit where it was first diagnosed. Option b is incorrect because history codes are secondary codes for conditions previously treated that no longer exist, and a chronic disease still under ongoing treatment does not fit that description. Option d is incorrect because the guidelines also direct coders to report coexisting conditions that require or affect care, so a chronic disease can be an additional diagnosis.

Correct Answer: A symptom

The outpatient guidelines direct that the reason chiefly responsible for the services be listed first. When the provider has not established a diagnosis, the first-listed diagnosis may be a symptom. Option a is incorrect because history codes serve only as secondary codes when a past or family condition affects current care, so they do not take the first-listed position here. Option c is incorrect because chronic diseases treated on an ongoing basis may be reported at each visit, but the guidelines do not make them first-listed when the reason for the visit is an unconfirmed problem. Option d is incorrect because terms indicating uncertainty, such as probable, suspected or rule out, are not coded in the outpatient setting, so such a diagnosis cannot be listed first.

Correct Answer: Assign both the Z code and the reason for the non-routine test

When routine testing is performed during the same encounter as a test to evaluate a sign, symptom or diagnosis, the outpatient guidelines state it is appropriate to assign both the Z code and the code describing the reason for the non-routine test. Option b is incorrect because the guidelines call for the reason for the non-routine test to be reported as well, so omitting the symptom leaves the encounter incompletely described. Option c is incorrect because the guidelines do not tell the coder to discard the routine testing code when a non-routine test is done during the same encounter. Option d is incorrect because the routine testing still has its own Z code, and the guidelines allow reporting both rather than dropping the examination code.

Correct Answer: Diagnosis and external cause of injury codes

The POA guidelines direct that an indicator be assigned for each diagnosis and external cause of injury code reported on inpatient claim forms, covering the principal and secondary diagnoses and the external cause of injury codes. Option a is incorrect because the guidelines name only diagnoses and external cause of injury codes as receiving an indicator, and procedure codes are not among the codes they list. Option b is incorrect because the indicator is applied to the final set of diagnosis codes already assigned under Sections I, II, and III, not to a separate group chosen by documentation status. Option c is incorrect because the indicator goes to the principal diagnosis and to the secondary diagnoses as well, plus external cause of injury codes, so a principal-only limit is too narrow.

Correct Answer: Assign codes for the documented manifestations

Coders follow Alphabetic Index guidance for syndromes. When the Index offers none, the guidelines direct assignment of codes for the documented manifestations of the syndrome, and additional manifestation codes may be added in some cases. Option a is incorrect because code selection belongs to the coder; the guidelines give no instruction to ask the provider for a code when the Index is silent. Option b is incorrect because a sequela is the residual effect after an acute illness or injury has ended, which is a separate concept from coding a syndrome. Option d is incorrect because the guidelines do not tell the coder to fall back on an unspecified syndrome code; they point to the manifestations the provider documented.

Correct Answer: The provider

Clinical indicators are documentation elements supporting a diagnosis, and the guidance states that the provider determines the clinical significance of each indicator. The number and type required may vary with the clinical scenario. Option b is incorrect because ancillary documentation can serve as a clinical indicator, yet it is only an input; the guidance does not give that professional the significance decision. Option c is incorrect because such a platform may generate queries to support valid documentation, but it acts as a tool and does not judge clinical significance. Option d is incorrect because query professionals, including CDI staff and coders, initiate or oversee queries to resolve documentation issues, but the guidance leaves clinical significance to the provider.